Oseltamivir for children with suspected influenza A H1N1
Due to the great relevance that pandemic influenza A (H1N1)
is having nowadays, specially about the controversy of using
neuraminidase inhibitors as empiric treatment in children,
we have consider as something important to study our
patients treated with oseltamivir and observe how many of
them had at the end a positive result of PCR (Polymerase
Chain Reaction) for influenza A H1N1. Our objective is to
think calmly about the use of antiviral drugs and to
describe the diagnosis in children that received initially
treatment at the time of admission without having truly
influenza A.
We took in clinical information from children that have been
admitted in our hospital with suspected influenza A, from
15th June to 15th October 2009. In total, we obtained data
of 133 children, 16 of them (12%) were patients from
Oncology Department. Rest of children were 107 (88%) no
oncological patients. The age range width of these last ones
patients was from 19 days to 16 years old, with a median age
of 2,9 years; being 54.2% of them males. Nasal swabs samples
were collected from all patients to analyse PCR for H1N1
and, before knowing the results, 57 (42,8%) of them received
empiric treatment with oseltamivir:
(here goes table 1 [added 1 November 2009])
Number of children treated with oseltamivir
PCR H1N1 + PCR H1N1 -
Non oncolgical 18 (37,5%) 30 (62,5%) 48
Oncological 8 (88,8%) 1 (11,1%) 9
TOTAL 26 31 57
It can be observed that 62,5% of the non oncological
children received empiric treatment without being infected
with influenza A H1N1. We believe a debate should be opened
about current criteria to prescribe antiviral treatment at
the time of admission, because these criteria are in general
quite a lot wide and includes very frequent symptoms in this
season, as fever, cough, mucus, difficult respiratory,
pneumonia,… On second thought, we have to mention that these
criteria have been restricted during the time of the study,
and at the current time, they are more strict, giving the
physicians the choice to treat or not, depending on the
individual characteristics of the patient.
Moreover, final diagnosis of non oncological
children who received empiric treatment with oseltamivir and
finally had PCR H1N1 negative (30 patients) were:
- 13 patients (43%) Acute asthmatic crisis
- 7 patients (23%) Pneumonia (2 of these 7 had also pleural
effusion)
- 4 patients (13%) Fever syndrome
- 3 patients (10%) Laryngitis
- 2 patients (6%) Viral infection
- 1 patient (3%) Acute otitis media
Therefore, we can deduce that overall difficult
respiratory and cough (very frequent in asthma and
pneumonia) make physicians think in influenza A, because
these symptoms are strongly associated with a high pre-test
possibility of having H1N1 infection (and so to received
antiviral treatment). We may note that having any kind of
pneumonia has been sometimes a criterion to give oseltamivir
treatment, just to prevent possible severe complications of
infection or coinfection of H1N1.
Official criteria to prescribe neuraminidase
inhibitors for treatment in children are constantly updated.
Knowing the uncertain data about its real effectiveness
preventing severe cases (1); secondary effects that have
been reported (2) (although we declare that in our patients
we had no unintended effects) and the special susceptibility
of children (3), it may be good to have a critical
reflection before prescribing oseltamivir.
1 Shun-Shin M, Thompson M. Neuraminidase inhibitors for
treatment and prophylaxis of influenza in children:
systematic review and meta-analysis of randomised controlled
trials. BMJ. 2009 Aug 10;339:b3172.
2. Strong M, Burrows J, Redgrave P. A/H1N1 pandemic.
Oseltamivir's adverse events. BMJ. 2009 Aug 11;339:b3249
3. Jefferson T, Jones M, Doshi P, Del Mar C Possible harms
of oseltamivir--a call for urgent action. Lancet. 2009 Oct
17;374(9698):1312-3
Competing interests:
None declared
Competing interests:
Number of children treated with oseltamivir PCR H1N1 + PCR H1N1 - Non oncolgical 18 (37,5%) 30 (62,5%) 48 Oncological 8 (88,8%) 1 (11,1%) 9TOTAL 26 31 57
29 October 2009
Marta Gómez Fernández-Vegue
Medical Resident (Pediatrics)
Yolanda Tovar Vicente, Marciano Sánchez Bayle, and Julia Cano
Rapid Response:
Oseltamivir for children with suspected influenza A H1N1
Due to the great relevance that pandemic influenza A (H1N1)
is having nowadays, specially about the controversy of using
neuraminidase inhibitors as empiric treatment in children,
we have consider as something important to study our
patients treated with oseltamivir and observe how many of
them had at the end a positive result of PCR (Polymerase
Chain Reaction) for influenza A H1N1. Our objective is to
think calmly about the use of antiviral drugs and to
describe the diagnosis in children that received initially
treatment at the time of admission without having truly
influenza A.
We took in clinical information from children that have been
admitted in our hospital with suspected influenza A, from
15th June to 15th October 2009. In total, we obtained data
of 133 children, 16 of them (12%) were patients from
Oncology Department. Rest of children were 107 (88%) no
oncological patients. The age range width of these last ones
patients was from 19 days to 16 years old, with a median age
of 2,9 years; being 54.2% of them males. Nasal swabs samples
were collected from all patients to analyse PCR for H1N1
and, before knowing the results, 57 (42,8%) of them received
empiric treatment with oseltamivir:
(here goes table 1 [added 1 November 2009])
It can be observed that 62,5% of the non oncological
children received empiric treatment without being infected
with influenza A H1N1. We believe a debate should be opened
about current criteria to prescribe antiviral treatment at
the time of admission, because these criteria are in general
quite a lot wide and includes very frequent symptoms in this
season, as fever, cough, mucus, difficult respiratory,
pneumonia,… On second thought, we have to mention that these
criteria have been restricted during the time of the study,
and at the current time, they are more strict, giving the
physicians the choice to treat or not, depending on the
individual characteristics of the patient.
Moreover, final diagnosis of non oncological
children who received empiric treatment with oseltamivir and
finally had PCR H1N1 negative (30 patients) were:
- 13 patients (43%) Acute asthmatic crisis
- 7 patients (23%) Pneumonia (2 of these 7 had also pleural
effusion)
- 4 patients (13%) Fever syndrome
- 3 patients (10%) Laryngitis
- 2 patients (6%) Viral infection
- 1 patient (3%) Acute otitis media
Therefore, we can deduce that overall difficult
respiratory and cough (very frequent in asthma and
pneumonia) make physicians think in influenza A, because
these symptoms are strongly associated with a high pre-test
possibility of having H1N1 infection (and so to received
antiviral treatment). We may note that having any kind of
pneumonia has been sometimes a criterion to give oseltamivir
treatment, just to prevent possible severe complications of
infection or coinfection of H1N1.
Official criteria to prescribe neuraminidase
inhibitors for treatment in children are constantly updated.
Knowing the uncertain data about its real effectiveness
preventing severe cases (1); secondary effects that have
been reported (2) (although we declare that in our patients
we had no unintended effects) and the special susceptibility
of children (3), it may be good to have a critical
reflection before prescribing oseltamivir.
1 Shun-Shin M, Thompson M. Neuraminidase inhibitors for
treatment and prophylaxis of influenza in children:
systematic review and meta-analysis of randomised controlled
trials. BMJ. 2009 Aug 10;339:b3172.
2. Strong M, Burrows J, Redgrave P. A/H1N1 pandemic.
Oseltamivir's adverse events. BMJ. 2009 Aug 11;339:b3249
3. Jefferson T, Jones M, Doshi P, Del Mar C Possible harms
of oseltamivir--a call for urgent action. Lancet. 2009 Oct
17;374(9698):1312-3
Competing interests:
None declared
Competing interests: Number of children treated with oseltamivir PCR H1N1 + PCR H1N1 - Non oncolgical 18 (37,5%) 30 (62,5%) 48 Oncological 8 (88,8%) 1 (11,1%) 9TOTAL 26 31 57